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Ray Lewis is a 67 year old man who was admitted to hospital with the diagnosis of a probable bowel obstruction. Mr Lewis had a history of two myocardial infarctions (MI) and chronic obstructive pulmonary disease (COPD). A surgeon was consulted and Mr Lewis underwent surgery that afternoon. A cancerous growth was removed from his colon and a permanent colostomy was performed. He returned to the unit you are working on several days later, alert, oriented and aware of his condition. Mr Lewis chats to you about his condition and tells you he has two daughters that live interstate. Apparently, he has not seen them for a number of years, although he did talk to them occasionally on the phone. Mr Lewis and his wife separated about five years ago, and by all accounts, the divorce was an acrimonious one. He tells you that his daughters sided with their mother after the divorce, however, over the last couple of years, he thought their relationship had been improving. About six months ago, Mr Lewis met a woman and started a new relationship with her. When he told his daughters about this, they became quite upset with him again. He fears that this new relationship has de-railed the relationship he was trying to repair with his daughters. Mr Lewis‟s partner, Lisa Alvarez, arrives that evening to visit him. She is very attentive toward Mr Lewis and is very concerned about him. Mr Lewis seems to be much happier when she is around. You also read in the nursing notes that Lisa is listed as his next-of-kin. Just before Lisa was due to leave the hospital, one of Mr Lewis‟s daughters, Alice, called the nurses‟ station. Alice is enquiring about her father‟s condition and seems unaware of his recent diagnosis of bowel cancer. You advise her that Mr Lewis‟s condition is stable and put the call through to his room so he could talk to his daughter in person. By the end of the afternoon shift at around 11.00 pm Mr Lewis‟s urinary output was only 90 ml. You contact the resident on call and receive a phone order to increase his IV fluid rate along with an IV diuretic, and other appropriate measures. Although these treatments were administered successfully, Mr Lewis‟s urinary output failed to increase significantly during the night. By the next afternoon, when you commence the afternoon shift, Mr Lewis‟s condition has deteriorated markedly. He has become very restless and confused, and is constantly pulling out his nasal prongs that are delivering oxygen. You go through the notes for any information relating to a „Do Not Resuscitate‟ order, or an Advance Care Directive, but can find nothing. By about 8 pm, Mr Lewis was very sweaty and extremely lethargic and he started developing Cheyne-Stokes respirations. The resident was notified, but no additional orders were given, and he did not come to see Mr Lewis. Lisa Alvarez had been with Mr Lewis all afternoon and evening, and she tells you that Mr Lewis did not want any “heroic measures taken”. She says that they had discussed this issue on a number of occasions, and that all Mr Lewis wanted was to be kept comfortable. He certainly did not want to be “hooked up to machines” and said that if he was going to die, he wanted to die “quickly and painlessly, with no fuss”. Lisa tells you that Mr Lewis had 2 watched his father die of cancer many years ago and despaired at the “futile and senseless treatment” the staff had put him through. Mr Lewis believed his father had been “treated much worse than you‟d treat a dog” and that he “hadn‟t been allowed to die”. Lisa tells you that this experience had been instrumental in forming Mr Lewis‟s ideas about death. You assure Lisa that you will record this information and notify the resident on call. At 8.30 pm Alice phones again enquiring about her father. You inform her of Mr Lewis‟s deteriorating condition. Alice and her sister, Sarah, are adamant that they want everything possible done for their father, and that they would be arriving at the hospital tomorrow afternoon. They are annoyed that there has been such a marked deterioration and demand to know what has happened. You tell Alice about the discussion with Lisa, however, this does not please Alice; “We are the real next-of-kin” she said “They‟re not even married! I don‟t want that woman making any decisions about dad!” You try to placate Alice by telling her that her wishes would be taken into consideration, and that you were going to call the doctor again and inform him of the situation. Before you have a chance to phone the resident, Mr Lewis goes into cardiac arrest. For a brief moment you wonder what you should do, then you call for the resuscitation trolley

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